C-CDA on FHIR Implementation Guide STU 1 (v1.0.0)
This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
<Composition xmlns="http://hl7.org/fhir"> <id value="CCDA-on-FHIR-Discharge-Summary-Example"/> <meta> <versionId value="1"/> <lastUpdated value="2016-06-15T08:16:14Z"/> <profile value="http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Discharge-Summary"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document Id</span> </td> <td class="td_header_role_value">12345</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document Created:</span> </td> <td class="td_header_role_value">June 15, 2016, 16:14, PST </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Discharge Summary</span> </td> <td class="td_header_role_value">Discharge Summary for Amy Shaw</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Performer </span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Author</span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Encounter Id</span> </td> <td class="td_header_role_value">9937012 2.16.840.1.113883.19</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Encounter Type</span> </td> <td class="td_header_role_value">Discharge</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Event Date</span> </td> <td class="td_header_role_value"> From June 15, 2016, 16:20 to June 15, 2016, 18:20 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Encounter Location</span> </td> <td class="td_header_role_value">Inpatient Unit at Community Health and Hospitals</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Responsible party</span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Assigned entity</span> </td> <td class="td_header_role_value">Community Health and Hospitals<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Emergency contact</span> </td> <td class="td_header_role_value">Michael Shaw<br/> <br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">49 Meadow St<br/>Amherst MA 01003, US<br/>Tel: (555)555-1212<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Care giver</span> </td> <td class="td_header_role_value">Mrs. Lillian White<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">49 Meadow St<br/>Amherst MA 01003, US<br/>Tel: (555)555-1215<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Entered by</span> </td> <td class="td_header_role_value">Sally Jones</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Signed </span> </td> <td class="td_header_role_value">Ronald Boone at June 15, 2016 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Informant</span> </td> <td class="td_header_role_value">Henry Vincent, CPh</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1007 Pharmacy Drive<br/>Portland, OR 99123, US<br/>Tel: +1(555)555-1215<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Information recipient:</span> </td> <td class="td_header_role_value">Primary Physician, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1005 St. Clair Avenue<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1666<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Legal authenticator</span> </td> <td class="td_header_role_value">Ronald Boone, MD signed at June 15, 2016 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document maintained by</span> </td> <td class="td_header_role_value">Community Health and Hospitals</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> </div> </text> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="1"/> </identifier> <status value="preliminary"/> <type> <coding> <system value="http://loinc.org"/> <code value="18842-5"/> <display value="Discharge Summary"/> </coding> </type> <!-- Patient Resource --> <subject> <reference value="Patient/patient-1"/> <display value="Amy V. Shaw"/> </subject> <date value="2016-02-28T09:10:14Z"/> <!-- Practitioner Resource --> <author> <reference value="Practitioner/practitioner-1"/> <display value="Ronald Boone, MD"/> </author> <title value="Discharge Summary(CCoF)"/> <confidentiality value="N"/> <!-- Organization Resource --> <custodian> <reference value="Organization/organization-1"/> <display value="Community Health and Hospitals"/> </custodian> <!-- Encounter Resource --> <!-- <encounter><reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/></encounter> --> <!-- Allergies and Intolerances Section Narrative --> <section> <title value="Allergies and Intolerances Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="48765-2"/> <display value="Allergies and adverse reactions"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Substance</b> </td> <td> <b>Overall Severity</b> </td> <td> <b>Reaction</b> </td> <td> <b>Reaction Severity</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Cashew Nut</td> <td>Severe</td> <td>Anaphylactic reaction</td> <td>Mild</td> <td>Active</td> </tr> </table> </div> </text> <mode value="snapshot"/> <orderedBy> <coding> <system value="http://hl7.org/fhir/list-order"/> <code value="event-date"/> <display value="Sorted by Event Date"/> </coding> </orderedBy> <!-- Allergies and Intolerances Section Resource --> <entry> <reference value="AllergyIntolerance/allergy-intolerance"/> </entry> </section> <!-- Chief Complaint and Reason for Visit Section Narrative --> <section> <title value="Chief Complaint and Reason for Visit Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="46239-0"/> <display value="Chief complaint and reason for visit"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Cramping, bloating, and constipation.</p> </div> </text> </section> <!-- Chief Complaint Section Narrative --> <section> <title value="Chief Complaint Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10154-3"/> <display value="Chief complaint"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Dark Stools</p> </div> </text> </section> <!-- Reason for Visit Section Narrative --> <section> <title value="Reason for Visit Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="29299-5"/> <display value="Reason for visit"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Tenderness of lower abdomen</p> </div> </text> </section> <!-- Admission Diagnosis Section Narrative --> <section> <title value="Admission Diagnosis Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="46241-6"/> <display value="Hospital admission diagnosis"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Appendicitis</p> </div> </text> </section> <!-- Admission Medications Section Narrative --> <section> <title value="Admission Medications Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="42346-7"/> <display value="Medications on admission"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Medication</b> </td> <td> <b>Directions</b> </td> <td> <b>Start Date</b> </td> <td> <b>Status</b> </td> <td> <b>Indications</b> </td> <td> <b>Fill Instructions</b> </td> </tr> <tr> <td>Pepcid Complete (MAGNESIUM HYDROXIDE0</td> <td>Chew one tablet completely and swallow as needed </td> <td>20160615</td> <td>Active</td> <td>Bloating</td> <td>Generic substitution allowed</td> </tr> </table> </div> </text> </section> <!-- History of Past Illness Section Narrative --> <section> <title value="History of Past Illness Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11348-0"/> <display value="History of past illness"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Problem Name</b> </td> <td> <b>Type</b> </td> <td> <b>Onset Date</b> </td> <td> <b>Abatement Date</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Fever</td> <td>Condition</td> <td>2016-06-15</td> <td>2016-06-15</td> <td>Complete</td> </tr> </table> </div> </text> <!-- History of Past Illness Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- History of Present Illness Section Narrative --> <section> <title value="History of Present Illness Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10164-2"/> <display value="History of present illness"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>This patient was only recently discharged for a recurrent GI bleed as described below. </p> <p>He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... </p> <p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. </p> <p>He was transfused with 6 units of packed red blood cells with .... .... .... </p> <p>GI evaluation 12 September: Colonoscopy showed single red clot in .... ........ </p> </div> </text> </section> <!-- Review of Systems Section Narrative --> <section> <title value="Review of Systems Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10187-3"/> <display value="Review of systems"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands. </p> </div> </text> </section> <!-- Family History Section Narrative --> <!-- Family History Section Resource --> <!-- <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"/></entry> --> <section> <title value="Family History Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10157-6"/> <display value="History of family member diseases"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Relationship</b> </td> <td> <b>Diagnosis</b> </td> <td> <b>Age at Onset</b> </td> </tr> <tr> <td>Father</td> <td>Myocardial Infarction(cause of Death)</td> <td>57</td> </tr> <tr> <td>Father</td> <td>Diabetes</td> <td>40</td> </tr> </table> </div> </text> </section> <!-- Social History Section Narrative --> <section> <title value="Social History Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="29762-2"/> <display value="Social history"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Social History Element</b> </td> <td> <b>Description</b> </td> <td> <b>Effective Dates</b> </td> </tr> <tr> <td>Smoking</td> <td>1 pack tobacco per day</td> <td>2005/05/01 - 2010/02/28</td> </tr> </table> </div> </text> <!-- Social History Section Observation Resource --> <entry> <reference value="Observation/observation-smoker"/> </entry> </section> <!-- Functional Status Section Narrative --> <section> <title value="Functional Status Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="47420-5"/> <display value="Functional status"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Functional or Cognitive Finding</b> </td> <td> <b>Observation</b> </td> <td> <b>Observation Date</b> </td> <td> <b>Condition Status</b> </td> </tr> <tr> <td>Ambulation (Dependent to Independent</td> <td>Independently able</td> <td>2010/03/11</td> <td>Active</td> </tr> <tr> <td>Finding of Functional Performance and Activity</td> <td>Dyspnea</td> <td>2008/02/16</td> <td>Active</td> </tr> <tr> <td>Cognitive Function Finding</td> <td>Memory Impairment</td> <td>2014/04/29</td> <td>Active</td> </tr> </table> </div> </text> </section> <!-- Hospital Course Section Narrative --> <section> <title value="Hospital Course Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="8648-8"/> <display value="Hospital course"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Following a colonoscopy, the patient was admitted and started on Lovenox and nitroglycerin paste. The patient had serial cardiac enzymes and was ruled out for myocardial infarction. The patient underwent a dual isotope stress test. There was no evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated. The patient had a Holter monitor placed but the report is not available at this time. The patient has remained hemodynamically stable. Will discharge.</p> </div> </text> </section> <!-- Hospital Consultations Section Narrative --> <section> <title value="Hospital Consultations Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="18841-7"/> <display value="Hospital consultations"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>listType="ordered"</p> <p>Gastroenterology</p> <p>Cardiology</p> <p>Dietitian</p> </div> </text> </section> <!-- Plan of Treatment Section Narrative --> <section> <title value="Plan of Treatment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="18776-5"/> <display value="Plan of treatment"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Planned Activity</b> </td> <td> <b>Period</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Colonoscopy</td> <td>2016/08/16 - 2016/08/16</td> <td>Completed</td> </tr> <tr> <td>Recommendation to Exercise</td> <td>2016/06/29</td> <td>Ongoing</td> </tr> </table> </div> </text> </section> <!-- Problem Section Narrative --> <section> <title value="Problem Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11450-4"/> <display value="Problem list"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Problem Name</b> </td> <td> <b>Type</b> </td> <td> <b>Onset Date</b> </td> <td> <b>Abatement Date</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Fever</td> <td>Condition</td> <td>2016-04-01</td> <td>2016-04-14</td> <td>Complete</td> </tr> </table> </div> </text> <!-- Problem Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- Procedures Section Narrative --> <section> <title value="Procedures Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="47519-4"/> <display value="History of procedures"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Procedure Name</b> </td> <td> <b>Body Site</b> </td> <td> <b>Performer</b> </td> <td> <b>Date Performed</b> </td> <td> <b>Reason</b> </td> </tr> <tr> <td>Appendectomy (Procedure)</td> <td>Abdomen</td> <td>Dr. Adam Everyman</td> <td>20160405</td> <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td> </tr> </table> </div> </text> <!-- Procedures Section Resource --> <entry> <reference value="Procedure/procedure-rehab"/> </entry> </section> <!-- Discharge Diagnosis Section Narrative --> <section> <title value="Discharge Diagnosis Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11535-2"/> <display value="Hospital discharge diagnosis"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Diverticula of intestine</p> </div> </text> </section> <!-- Discharge Medications Section (entries required) Narrative --> <section> <title value="Discharge Medications Section (entries required)"/> <code> <coding> <system value="http://loinc.org"/> <code value="10183-2"/> <display value="Hospital discharge medications"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Medication</b> </td> <td> <b>Directions</b> </td> <td> <b>Start Date</b> </td> <td> <b>Status</b> </td> <td> <b>Indications</b> </td> <td> <b>Fill Instructions</b> </td> </tr> <tr> <td>Acetaminophen Tab 325 mg</td> <td>Take 2 tablet(s) every four hours if needed</td> <td>20160618</td> <td>Active</td> <td>Pain management</td> <td>Generic substitution allowed</td> </tr> </table> </div> </text> </section> <!-- Hospital Discharge Instructions Section Narrative --> <section> <title value="Hospital Discharge Instructions Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="8653-8"/> <display value="Hospital discharge instructions"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Take all of your prescription medication as directed. </p> <p>Make an appointment with your doctor to be seen two weeks from the date of your procedure. </p> <p>You may feel slightly bloated after the procedure because of air that was introduced during the examination. </p> <p> Call your physician if you notice: <br/> Bleeding or black stools. <br/> Abdominal pain. <br/> Fever or chills. <br/> Nausea or vomiting. <br/> Any unusual pain or problem. <br/> Pain or redness at the site where the intravenous needle was placed. <br/> </p> <p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given. </p> <p>Do not drive or operate machinery for 24 hours.</p> </div> </text> </section> <!-- Hospital Discharge Physical Section Narrative --> <section> <title value="Hospital Discharge Physical Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10184-0"/> <display value="Hospital discharge physical"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>GENERAL: Well-developed, slightly obese man. </p> <p>NECK: Supple, with no jugular venous distension.</p> <p>HEART: Intermittent tachycardia without murmurs or gallops. </p> <p>PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.</p> <p>EXTREMITIES: Free of edema.</p> </div> </text> </section> <!-- Hospital Discharge Studies Section Narrative --> <section> <title value="Hospital Discharge Studies Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11493-4"/> <display value="Hospital discharge studies summary"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table border="1" width="100%"> <thead> <tr> <th>Laboratory Information</th> <th>Chemistries and drug levels</th> </tr> </thead> <tbody> <tr> <td>Potasium</td> <td>4.0</td> </tr> <tr> <td>NA (135-145meq/l)</td> <td>140</td> </tr> </tbody> </table> <br/> <table border="1" width="100%"> <thead> <tr> <th>Other Tests</th> <th>Results</th> </tr> </thead> <tbody> <tr> <td>EKG</td> <td>Sinus rhythm without acute changes.</td> </tr> </tbody> </table> </div> </text> </section> <!-- Immunizations Section Narrative --> <section> <title value="Immunizations Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11369-6"/> <display value="History of immunization"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Vaccine</b> </td> <td> <b>Date</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Fluvax (Influenza)</td> <td>2016-04-05</td> <td>Completed</td> </tr> </table> </div> </text> <!-- Immunizations Section Resource --> <entry> <reference value="Immunization/immunization"/> </entry> </section> <!-- Nutrition Section Narrative --> <section> <title value="Nutrition Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="61144-2"/> <display value="Diet and nutrition"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Date</b> </td> <td> <b>Nutritional Status</b> </td> <td> <b>Diet</b> </td> </tr> <tr> <td>2016/06/15</td> <td>Well nourished</td> <td>Low sodium diet, excessive carbohydrate</td> </tr> <tr> <td>2016/06/15</td> <td>Slight dehydration</td> <td>High protein, low fibre</td> </tr> </table> </div> </text> </section> <!-- Vital Signs Section Narrative --> <section> <title value="Vital Signs Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="8716-3"/> <display value="Vital signs"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Vital Sign</b> </td> <td> <b>Date</b> </td> <td> <b>Value</b> </td> </tr> <tr> <td>Temperature</td> <td>2016/06/15</td> <td>39 Degrees Celcius</td> </tr> </table> </div> </text> <!-- Vital Signs Section Observation Resource --> <entry> <reference value="Observation/observation-vitals-temp"/> </entry> </section> </Composition>
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